A national prescribing examThe Prescribing Safety Assessment

PSAJuly 2015

Patricia McGettiganClinical Senior Lecturer in Clinical

Pharmacology

Today

• GMC requirements in respect of clinical pharmacology, therapeutics and prescribing

• PSA background – summary• PSA structure, topics, domains• Question templates & examples• Clinical Pharmacology & Therapeutics (CPT)

during Years 3-5, Barts and The London • PSA experience at Barts and The London

Tomorrow’s Doctors 2009Clinical pharmacology, therapeutics,

prescribing outcomesThe doctor as a scholar and a scientist

Outcome 8f The graduate will be able to demonstrate

knowledge of drug actions therapeutics and pharmacokinetics; drug side effects and interactions, including for multiple treatments, longterm conditions and non-prescribed medication; and also including effects on the population, such as the spread of antibiotic resistance.

The doctor as a practitioner Outcome 17. Able to Prescribe drugs safely, effectively and economically

(a) Establish an accurate drug history, covering both prescribed and other medication.

(b) Plan appropriate drug therapy for common indications, including pain and distress.

(c) Provide a safe and legal prescription.(d) Calculate appropriate drug doses and record the outcome accurately.(e) Provide patients with appropriate information about their medicines.(f) Access reliable information about medicines.(g) Detect and report adverse drug reactions.(h) Demonstrate awareness that many patients use complementary and

alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.

PSA BACKGROUND

Drugs as risk factors in patient well-being

EQUIP Study 2009 GMC

• 11,077 errors were detected in 124,260 medication orders checked on seven ‘census days’ in 19 acute hospital trusts

• FY1 and FY2 doctors write most hospital prescriptions – FY1 doctors write 40% of hospital prescriptions (50k)– FY2: write 28%– Consultants: write just 3%

• Prescribing is risky: Errors in 8%-11% of FY1 & FY2 prescriptions

On-line: 24 stations; Prescribing has 8 stations; other sections have 2-4 questions each BNF is the only reference permittedhttps://prescribingsafetyassessment.ac.uk/aboutpsa

PSA Design

8 question types• Prescribing• Prescription review• Planning management• Communicating

information• Drug dose calculation• Adverse drug reactions• Drug monitoring• Data interpretation

7 domains

• Medicine• Surgery• Elderly care• Paediatrics• Psychiatry• Obs & Gyn• General Practice

https://prescribingsafetyassessment.ac.uk/aboutpsa

PSA Question Section and Domain grid

Question writing and standard setting

• Question writing– Initial author– Editors review (2)– Peer-review (groups of 8)– Exam board review (groups of 6)

• Standard Setting • January each year – groups of 10 reviewers – mixed skills• MSC Assessment oversight

SOME QUESTION EXAMPLES

Templates With thanks to Dr Fu Ng

https://prescribingsafetyassessment.ac.uk/aboutpsa

CAL – Calculation

• Examples include– Correct number of tablets to achieve required dose– Dose adjustments based on weight or body surface area– Diluting a drug for administration in infusion pump.– Convert different expressions of drug doses and

concentrations.

• 1, 2, 3 or very rarely 4 step calculations.

Calculation Skills Item CAL000ID This item is worth 2 marks You may use a calculator at any time

Case presentationA [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. You are required to give a dose of ...etc. The patient weighs …[The case presentations should be fairly brief – 2 or 3 sentences]

CalculationWhat [total amount/volume/duration/total dose etc.] should the patient [be given, etc.] …… ? (Write your answer in the box below)

Answer boxCorrect answer

Write the correct answer with units in this box

Working

Write a brief justification of the answer in this box, sufficient to explain how to calculate the correct answer

Answer unit

Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Calculation Skills Item CAL000ID This item is worth 2 marks You may use a calculator at any time

Case presentationA 45-year-old man with type 2 diabetes mellitus attends his GP. His weight has been problematic; consideration is being given to an anti-obesity drug. Eligibility for treatment depends on his body mass index (BMI). His weight is 97.2 kg and height is 1.8 m.

CalculationWhat is his body mass index based on these measurements?

Answer boxCorrect answer

Write the correct answer with units in this box

Working

Write a brief justification of the answer in this box, sufficient to explain how to calculate the correct answer

Answer unit

Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

DAT – Data interpretation

• Interpreting data in light of clinical scenario and deciding most appropriate action, may involve– Withdrawing a medicine– Reducing dose– No change – Increasing dose– Prescribing new medicine.

• Examples might include– Drug concentrations – Drug effects (e.g. INR / TFT / Chol / BP)– Drug side effects (e.g. U+E, FBC, CK)– Nomograms (e.g. paracetamol)

Data Interpretation Item DAT000ID This item is worth 2 marks You may use the BNF at any time

DECISION OPTIONS

A Option A ☐

B Option B ☐

C Option C ☐

D Option D ☐

E Option E ☐

Case presentationA [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history][Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief but identify the treatment for which a decision is required, the therapeutic indication and sufficient information about the patient to for the candidate to be able to identify the best decision option]

QuestionSelect the most appropriate decision option with regard to [the xxxx prescription/the treatment of xxxxxx] based on these data.(mark it with a tick)

Place 5 plausible options in the boxes provided, describing each with

clarity

Identify the correct answer by placing a tick in the column

on the right

Answer boxOption A Justification

Write a brief justification in this box

Option B Justification

Write a brief justification in this box

Option C Justification

Option D Justification

Option E Justification

Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

TDM – Drug monitoring

• Involves making judgement about the impact of ongoing / planned treatments.

• Duration of effects; Beneficial and harmful effects• ‘Culprit’ drugs• Monitoring (and correct timing) including

– Clinical symptoms & signs; Investigations

• Examples requiring monitoring– Digoxin for atrial fibrillation – Inhaled corticosteroids for asthma– Thyroxine for hypothyroidism

Drug Monitoring Item TDM000ID This item is worth 2 marks You may use the BNF at any time

MONITORING OPTIONS

A Option A ☐

B Option B ☐

C Option C ☐

D Option D ☐

E Option E ☐

Case presentationA [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history][Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief but identify the treatment that is being started, the therapeutic indication and sufficient information about the patient for the candidate to be able to identify the best monitoring option]

QuestionSelect the most appropriate monitoring option to assess the [beneficial/adverse] effects of this treatment.(mark it with a tick)

Place 5 plausible monitoring options in the

boxes provided, describing each with

clarity

Identify the correct answer by placing a tick in the column

on the right

Answer boxOption A Justification

Write a brief justification in this box

Option B Justification

Write a brief justification in this box

Option C Justification

Option D Justification

Option E Justification

Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Answer

• Plasma HIV RNA • (Viral load)

• Strategic Timing of AntiRetroviral Treatment (START) study,

• May 27, 2015• http://www.niaid.nih.gov/news/QA/Pages/

STARTqa.aspx

REV – Prescribing review

• Involves interpreting list of medicines in light of a clinical problem – Spotting important drug interactions– Serious dosing errors– Suboptimal prescriptions

• Total list of medicines for each question item ≥6. • Some knowledge of common effects, adverse

reactions and interactions will be assumed.• Dosing errors• Interactions

Prescribing Skills Assessment – Prescription Review Question Item Example

Prescription Review Item REV000ID This question item is worth 4 marks You may use the BNF at any time

CURRENT PRESCRIPTIONS

Drug name Dose Route Freq. A B

Drug 1 xx mg IV daily ☐ ☐

Drug 2 xx mg ORAL 12-hrly ☐ ☐

Drug 3 xx mg ☐ ☐

Drug 4 xx mg ☐ ☐

Drug 5 xx mg ☐ ☐

Drug 6 xx mg ☐ ☐

Drug 7 xx mg ☐ ☐

Drug 8 xx mg ☐ ☐

Drug 9 xx mg ☐ ☐

Drug 10 xx mg ☐ ☐

Case presentationA [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] His current regular medicines are listed (right). [Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief]

Question ASelect the [ONE/TWO/THREE prescription/prescriptions] that [is/are] [most likely to be a cause of/contains a serious dosing error/interact/is contra-indicated, etc.].(mark [it/them] with a tick in column A)

Question BSelect the [ONE/TWO/THREE prescription/prescriptions] that [is/are] [contra-indicated/most likely to be a cause of/contains a serious dosing error/interact/, etc.].(mark [it/them] with a tick in column B)

Use between 5 and 10 rows to create the list of drugs that will form

the focus of Questions A and B

Identify the correct answer(s) on columns A and B and justify

in the answer box below

Answer box

Question A Marks per correct tick [1 or 2]

Write a brief justification in this box

Question B Marks per correct tick [1 or 2]

Write a brief justification in this box

PWS - Prescribing

• Acute and chronic conditions or symptoms• Deciding between different drugs, formulations,

routes, doses and frequencies• Typical prescriptions: high-risk (e.g. anticoagulants,

opioids, insulin); common (e.g. antibiotics); special dosing; fluids.

• The likely differential diagnosis should be clear from the scenario (but not necessarily be identified).

Case presentationA 68-year-old woman attends her GP after a recent manipulation under anaesthetic for a left Colles’ fracture. PMH. Recent diagnosis of osteoporosis. DH. Calcichew D3 Forte two tablets orally daily.

On examinationLeft forearm in plaster cast.

InvestigationsDEXA scan confirms osteoporosis.

Prescribing requestWrite a prescription for ONE drug will help reduce the risk of further fractures.(use the general practice prescription form provided)

PWS003ID This item is worth 10 marks You may use the BNF at any time Prescribing Item

Pharmacy Stamp

Please don’t stamp over age box

Age0yr 0mths

D.o.B.00/00/0000

Title, Forename, Surname & AddressPatient NameAddress Line 1Address Line 2Town Postcode

Number of days’ treatmentN.B. Ensure dose is stated 28

Endorsements Drug NameDoseFrequency

Signature of PrescriberSignature

Date00/00/0000

ForDispenserNo. ofPrescns.on form

Xxxxx Health AuthorityDr AddressTown PostcodeTel: 00000 000 000

FP10NC0105

Created by Department of Clinical Pharmacology, QMUL

Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that can’t be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.

PWS000ID This item is worth 10 marks You may use the BNF at any time Answer Page

C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription

D. Signature. Candidates will also be given 1 mark for signing the prescription

A. Drug choice Score Feedback/justification B. Dose and Posology Score Feedback/justification

1 Alendronic Acid 4 BNF recommended 1st line for post menopausal, secondary prevention of osteoporotic fractures

70mg ORAL once-weekly or 10mg once-daily 4 Recommended dose

2 10mg ORAL once-weeky 2 Too low

3 70mg ORAL daily 1 Danger of toxicity

4 Other doses 0 (not readily available)

5 Risedronate 3 2nd line for post menopausal, secondary prevention of osteoporotic fractures

Correct doses of weekly/daily dose of Risedronate (ORAL 35mg weekly or 5mg daily)

3 Recommended dose

6 5mg ORAL weekly 1 Too low

7 35mg ORAL daily 0 Danger of toxicity

8 Other doses 0 (not readily available)

9 Strontium ranelateRaloxifene

2 3rd line for post menopausal, secondary prevention of osteoporotic fractures

Correct doses of strontium (ORAL 2g daily), raloxifene (ORAL 60mg daily)

2 Correct doses (any other dose = 0 marks as not readily available)

10

Teriparatide 1 4th line for post menopausal, secondary prevention of osteoporotic fractures

20 micrograms SC daily 1

11

Any other drugs 0 Not indicated

12

Other bisphosphonates 2 Not recommended for osteoporosis orally Correct dose of other bisphosphonates 2

13

HRTCalcitriol

1 Recommended for corticosteroid induced osteoporosis as 2nd line to bisphosphonates

Correct dose of HRT/calcitriol 1

14

15

16

17

18

19

20

Prescribing Item

Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Case presentationA 13-year-old boy is assessed on the paediatric day unit for severe aural pain that has not improved despite 72 hours of treatment with simple analgesia. PMH. None. DH. Paracetamol 1 g orally as required. Allergic to penicillin. On examinationT 37.7 oC; HR 100/min; BP 100/68 mmHg. Otoscopy reveals intact red drum, bulging on right side.

Prescribing requestWrite a prescription for ONE drug that will treat his infection.(use the hospital ‘regular medicines’ prescription chart provided)

PWS002ID This question item is worth 10 marks

Date

Time

Drug (Approved name)

68Dose Route

12Prescriber – sign + print Start date 14

18Notes Pharmacy

22

You may use the BNF at any time Prescribing Item

Created by Department of Clinical Pharmacology, QMUL

Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that can’t be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.

PWS000ID This item is worth 10 marks You may use the BNF at any time Answer Page

C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription

D. Signature. Candidates will also be given 1 mark for signing the prescription

A. Drug choice Score Feedback/justification B. Dose and Posology Score Feedback/justification

1 Clarithromycin 4 BNF recommended 1st line for penicillin allergy 250 mg 12-hrly orally 4 Recommended dose/posology

2 500mg 12-hrly orally 3 Usually reserved for severe infections

3 500mg 12-hrly iv 2 Parenteral reserved for serious or systemic upset

4 Any other dose/timing/routh 0

5 Beta lactam antibiotic 0 POTENTIALLY LIFE-THREATENING Any dose of beta-lactam 0 POTENTIALLY LIFE-THREATENING

6 Other macrolide (erythromycin, azithromycin)

2 Likely to be effective, but not first line Correct dose timing length other macrolide 2

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Prescribing Item

Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

PSA at Barts & The London 2012 - 2015

• Formative: 2012-2014• Summative component of Finals 2015• Exam on 27th February 2015

• Major IT problem at PSA – slow/broken connection to online BNF• Extraordinary ‘First sit’ resit offered to 9 students with scores

under ‘satisfactory’ score• All but one passed

• PSA practice focus in Year 5 but PSA topics mean that attention during Year 4 is needed

• Increasing attention during Year 4 placements

Year PWS (80 marks)

REV (32 marks)

MAN (16 marks)

COM (12 marks)

CAL (16 marks)

ADR (16 marks)

TDM (16 marks)

DAT (12 marks)

Mean Score

Pass Rate

2012 75.6% 71.0% 71.0% 85.7% 79.6% 76.6% 42.8% 80.2% 73.9% 86%

2013 84.8% 69.2% 55.0% 86.6% 82.7% 63.6% 68.6% 71.6% 76.1% 92.72%

2014 A 84.3% 80.5% 74.3% 89.3% 80.6% 75.0% 57.6% 85.8% 80.7% 92.78%

2014 B 87.8% 77.5% 67.7% 87.3% 88.3% 70.8% 68.0% 86.3% 81.9% 93%

2015 83.5% 79.3% 64.6% 80.6% 81.5% 85.1% 74.1% 76.8% 80.0%97.35% (99.7%)

Mean category score as % of possible: Year 5 students 2012-15

CPT / Prescribing in Years 3 & 4Year 3 • Lecture series CPT• Prescribing workshops• Formative exam

Year 4• Specialty placements – each to include relevant therapeutics• CPT lectures (September, March, July) – overview / common

themes / principles of prescribing• SCRIPT Principles of Prescribing on-line modules – mandatory

coursework over 11 weeks Feb-March• QMUL on-line resources – core drugs list, history/ therapeutics

template, therapeutics exercises• Log Books – new requirement to include prescription writing (just

two/placement but it’s a start!)

Year 4, April 2015

• Mock PSA for Year 4 students• Exam conditions• On-line 1-hour exam • Q type proportions were the same as in the

Year 5 PSA 2-hour exam• No ‘pass’ score set

– On my experience, likely around 65%

Score summary

QMUL Candidates

>/=80%65%-79%

60%-64%

55%-59%

50%-54%

40%-49%

39% or less

267 31 114 51 32 23 13 3

12% 43% 19% 12% 9% 5% 1%

PSA Score Range

54% 31% 15%

Rounded %

PSA section score detail

PSA Section Max score for section

Students with scores of 0 in the section

Alerts

Prescribing 40 0Score <20: 37 students. 34/37 had scores <65%

Review 16 0 Score <8; 5 students

Calculation 8 41 32/41 had PSA Score <65%

TDM 8 9

Adverse Events 8 3

Management 8 5

Data 6 50 37/50 had PSA Score <65%

Communication 6 1

Year 4 in context of Year 5 performance

Year PWS (80 marks)

REV (32 marks)

MAN (16 marks)

COM (12 marks)

CAL (16 marks)

ADR (16 marks)

TDM (16 marks)

DAT (12 marks)

Mean Score

Pass Rate

2012 75.6% 71.0% 71.0% 85.7% 79.6% 76.6% 42.8% 80.2% 73.9% 86%

2013 84.8% 69.2% 55.0% 86.6% 82.7% 63.6% 68.6% 71.6% 76.1% 92.72%

2014 A 84.3% 80.5% 74.3% 89.3% 80.6% 75.0% 57.6% 85.8% 80.7% 92.78%

2014 B 87.8% 77.5% 67.7% 87.3% 88.3% 70.8% 68.0% 86.3% 81.9% 93%

2015 83.5% 79.3% 64.6% 80.6% 81.5% 85.1% 74.1% 76.8% 80.0%97.35% (99.7%)

Year 4 Mock

66.4% 77.4% 57.3% 83.8% 55.8% 77.4% 57.6% 40.2% 66.2% 54%*

*Assume pass score 65%

Mean category score as % of possible: Year 5 students 2012-15

Percentage of students using CPT activity

2014-2015 Total respondents = 137.

2013-2014 Total respondents = 47

SCRIPT (required) 100% (137) 100% (47)

QMUL exam (required) 96% (132) 96% (45)

Pharmacist (required) 100% (137) 91% (43)

Lectures 96% (132) 91% (43)

Workshops 69% (95) 68% (32)

Case series N/A 57% (27)

QMplus 50% (69) 43% (20)

PRESCRIBE (PSA website) 94% (129) 26% (12)

Drug SMD 43% (59) 21% (10)

What do Year 5 do to prepare for the PSA & for FY1 work?

Survey by Dr Claire Calderwood during PfP week; 137 respondents (41% Year 5 cohort)

Ranking of resources

Year 5: Preparedness for FY11. Do you feel prepared for your first day of work as an FY1 doctor? 2. Do you feel that there has been an improvement in your prescribing skills compared to one year ago?

Self-evaluation of prescribing skillsClaire Calderwood questions based on prior survey by Simon Maxwell)

Score1 = I cannot do this10 = Always Agree

Resources

• PSA Website https://prescribingsafetyassessment.ac.uk/aboutpsa

• Books– Pass the PSA by Will Brown & others; February

2014; Churchill Livingstone ISBN: 978-0-7020-5518-8 (£30 approx)

– Top 100 Drugs by Andrew Hitchings & others; 2014; Churchill Livingstone; ISBN: 0702055166 (£15 approx)

– Prescribing Scenarios at a Glance by Emma Baker & others; July 2014, Wiley-Blackwell (£26 approx)

• Library has some copies of all